"I have the pleasure to be Emily Carter's paediatrician and have known them since 2018. I am writing this letter at their request to give some background on the challenges that they face and my suggestions for how they may be better supported."
NATURE OF DISABILITY
- Cerebral Palsy, Spastic Quadriplegia
- Severity: Severe and permanent.
- Diagnosis confirmed by MRI and clinical examination.
FUNCTIONAL IMPACTS
- Significant impairments in mobility, self-care, and communication.
- GMFCS score: Level V.
- Vision impairment: Requires glasses for near vision.
- Speech and language assessment indicates significant expressive and receptive language delays.
- Impacts on daily activities:
- Self-care: Requires complete assistance with all aspects of personal care.
- Communication: Limited verbal communication; relies on augmentative and alternative communication (AAC) devices.
- Mobility: Non-ambulatory; requires a wheelchair for all mobility.
- Social interactions: Limited due to communication difficulties and physical limitations.
- Impacts are unlikely to improve with therapy or treatments.
- Assessment: GMFCS, ophthalmology report, speech and language assessment.
SOCIAL IMPACT
- Social impacts include social isolation and difficulty participating in community activities.
- Psychosocial assessment indicates emotional distress and social withdrawal.
- Effects on social interactions:
- Difficulty forming peer relationships.
- Limited participation in school and community events.
- Emotional health: Experiences frequent frustration and anxiety.
- Assessment: Psychosocial assessment.
ECONOMIC IMPACT
- Significant additional expenses related to care and equipment.
- Effects on income:
- Parents unable to work full-time due to caregiving responsibilities.
- No assessment available.
PREVIOUS TREATMENTS AND OUTCOMES
- Undergone extensive physiotherapy, occupational therapy, and speech therapy.
- Outcomes: Limited improvement in motor skills; significant improvement in communication through AAC devices.
SUGGESTIONS FOR ONGOING OR FUTURE SUPPORTS
- Continued access to physiotherapy, occupational therapy, and speech therapy.
- Funding for AAC device maintenance and upgrades.
- Respite care for the family.
- Support for educational needs.
I am hopeful for Emily's future and commend her and her family's commitment and resilience.
"I have the pleasure to be [patient's name]'s paediatrician and have known them since [manual input]. I am writing this letter at their request to give some background on the challenges that they face and my suggestions for how they may be better supported."
NATURE OF DISABILITY
(Record the diagnosed disability using precise medical terms from the notes. Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
(Describe the disability's severity and permanence based on available records. State: "Further confirmation required" if the notes do not provide clear evidence of permanency. Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
(Strictly adhere to the explicit information provided in the patient's notes. List each separate point on a new line started with a dash. Indicate sub-pointed with a new line and an indented dash. Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
FUNCTIONAL IMPACTS
(List the patient's functional impairments. Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
(Correspond these impairments with specific assessments: Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
(Use a GMSF score for cerebral palsy. Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
(Refer to an ophthalmology or optometrist report for vision impairment. Refer to an audiometry report for hearing impairment. Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
(Cite a cognitive assessment for intellectual disability. Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
(Enumerate how these impairments affect daily activities - such as self-care, communication, mobility, and social interactions - in dash point format, using indented dash points for sub-points. Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
(If impacts fluctuate, detail the nature and frequency of these changes and demonstrate how fluctuations hinder daily life using examples from the patient's experience. Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
(Identify if impacts can be improved with therapy or treatments. Cite intervention examples when stated. Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
(If improvement is unlikely, clearly state so. Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
(Refer to the relevant assessment as mentioned in the notes for each functional impact. Ensure there is a clear connection in your language linking the assessment to the impact. Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
(Do not mention assessments that are not specified in the notes. If no assessment is noted, then clearly state: "No assessment available" or "Assessment pending". Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
(If an assessment is pending, state: "NDIS to obtain assessment from accredited source." Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
SOCIAL IMPACT
(Detail the social impacts of the patient's condition. Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
(Connect social impacts to relevant assessments mentioned in the notes: Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
(Reference a psychosocial assessment for emotional distress or social withdrawal. Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
(Use a quality of life assessment for societal integration or isolation. Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
(Use bullet points to summarize effects on social interactions, community involvement, and emotional health. Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
(If notes lack an assessment for a specific social impact, directly state "No assessment available" or "Assessment pending". Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
(Next, consider the economic impacts of the patient's condition. Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
(Reflect on the available notes for any mention of financial effects. Remember, the doctor may not provide comprehensive details about economic implications. Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
(Create dashed points to outline known effects on employment, income, or additional expenses. Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
(Identify if impacts can be improved with therapy or treatments. Cite intervention examples when stated. Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
(If improvement is unlikely, clearly state so. Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
(If impacts fluctuate, detail the nature and frequency of these changes and demonstrate how fluctuations hinder daily life using examples from the patient's experience. Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
(If notes lack an assessment for a specific economic impact, again state "No assessment available" or "Assessment pending". Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
(Only use information in the notes. Avoid speculating or making assumptions. Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
PREVIOUS TREATMENTS AND OUTCOMES
(Describe the treatments the patient has undergone and their outcomes. Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
SUGGESTIONS FOR ONGOING OR FUTURE SUPPORTS
(Provide recommendations for future treatments and expected outcomes. Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
(Conclude the letter with a hopeful statement about the patient's future and an acknowledgement of they and their family's commitment and resilience. Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
(For each section, only include if explicitly mentioned in transcript or context, else omit section entirely. Never come up with your own patient details, assessment, plan, interventions, evaluation, or next steps—use only the transcript, contextual notes, or clinical note as reference for all information. If any information related to a placeholder has not been explicitly mentioned, do not state that in the output; simply leave the relevant placeholder or section out entirely. Use as many lines, paragraphs, or bullet points as needed to capture all relevant information from the transcript.)